Independence as a practice issue in occupational therapy: the safety clause.

This article reports findings from interviews that explored the meanings occupational therapists attach to independence as a value and a therapeutic goal in interactions with elderly clients. Through a historical review of the literature, we trace the changing use of this term and identify two analytically distinct concepts associated with it: independence as self-reliance in activity and independence as autonomy, self-determination, or choice. We show how the latter has emerged in contemporary service contexts to represent an ideal of client-centered practice for persons with chronic disabilities, such as frail elderly clients. Using a "critical incident" interview approach with 12 Australian occupational therapists, we identified the therapists' explicit and implicit understandings of independence as a value concept and practice issue. Our findings suggest that a mismatch often exists between idealized and practice-based talk about independence and that therapists narrativize this opposition around what we call "the safety clause." That is, therapists invoke concerns about safety and duty of care as a caveat to implementing their independence ideals and justifying the retention of professional control. We identify key issues that therapists need to address if the rhetoric of independence-related client-centered practice is to be achieved in reality.